The University of Pennsylvania's multitude of rapidly growing China connections can be viewed through a number of different prisms. Some focus on its manufacturing networks or banking system. Others see it in terms of civil engineering challenges or consumer purchasing trends. But Penn Professor Syngcuk Kim has a somewhat more intimate view. His daily vision is of China's widely opened mouth and 1.3 billion sets of teeth not particularly well cared for.

For the last five years, Kim, DDS, PhD, Penn Dental Medicine's Associate Dean of Global Affairs, has been regularly flying to China as part of a six-member team that has logged 25,000 in-China miles shuttling back and forth to a dozen cities. It has so far established major collaborative programs with the six university-level schools that constitute China's "Ivy League" of dental education.

Gigantic dental hospitals
Chinese dentistry is different from the U.S. For one thing, dental services are mostly delivered in government dental hospitals that are also dental schools. For another, those dental hospitals are gigantic in size -- like U.S. academic medical centers. Many log a million patients a year and have full surgical and in-patient treatment facilities because in China, along with teeth, dentistry "owns" oral cancer.

As in all other areas of health care delivery, China's dental system is struggling to upgrade itself to modern scientific standards as well as provide access to a vast population -- particularly outside the largest cities.

"When we first went to the Shanghai Dental School," said Kim, "we arrived at 8 a.m. and looked down the stairs to see large crowds below and asked 'Is there a fire or has something happened?' We were told, 'No, these are patients. They always start arriving at 5 a.m. to begin the daily wait'. We also learned there are so many patients and so few dentists that patient visits are often limited to 30 minutes."

One dentist per 6,500 people
Some dentist-to-population ratios help illustrate the situation: The U.S. has about 180,000 dentists for a population of 300 million, or a ratio of about 1 dentist per 1,670 people. China has about 200,000 dentists for a 1.3 billion population or a ratio of 1 dentist per 6,500 people.

Penn Dental Medicine Dean Denis Kinane pointed out that that lopsided China ratio is even more so because substantial numbers of the existing dentists are not trained up to contemporary standards. He also notes that China's large challenges offer equally large opportunities for institutions such as Penn that have the knowledge and experience that China's government and dental industry are seeking.

Day-long lines
That overall picture -- of patients routinely lining up to spend five to ten hours each day waiting for a health care visit, a huge national shortage of clinical professionals, and many working clinicians who need training in the latest tools and techniques -- is similar to what faculty members in Penn Medicine, the Wharton School, the Leonard Davis Institute (LDI) of Health Economics and Penn Nursing describe about their own experiences and observations as they become more involved in collaborative China activities.

Penn's health science schools
"The PWCC evolved out of Wharton School thinking about offering Executive Education in China and then -- still led by Wharton -- it morphed into a whole Penn initiative," explained Penn Vice Provost for Global Initiatives and LDI Senior Fellow Ezekiel Emanuel. "Health-related things are only one component of that and include the medical school and all of Penn's other health science areas."

One little-known fact Emanuel pointed out is that Penn's dental school -- rather than Penn Medicine -- has the most extensive China engagements to date. This isn't all that surprising, given that the Dental School has otherwise been heavily focusing its student recruitment efforts on countries across the arc of Asia from India to China. According to dental school Dean Kinane, 40 percent of the dental students now studying on the Penn campus are from Asian countries.

SIMULTANEOUS TRANSLATION DILEMMA

One of the least obvious but most important issues that Penn Dental Medicine is grappling with at the Penn Wharton China Center (PWCC) in Beijing is simultaneous translation. The center boasts state-of-the-art video conferencing facilities that enable Penn professors in Philadelphia to speak in real-time to auditorium-sized audiences in China. And while simultaneous English-to-Chinese translators are not uncommon in China, there is a critical shortage of those with expertise in dental and other medical terminologies.

"This is a key issue in telecommunications, even in our on-site seminars," said Penn's Syngcuk Kim. "Many of our lectures are sub-titled in Chinese but the audience wants real-time translation for face-to-face telecommunications."

"As its health care collaborations with Western universities like Penn continue to expand," Kim said, "China is going to have to produce more simultaneous translators who are up to speed in the language of dental science."

Chair of the Penn Dental Medicine's Board of Overseers and a member of the University Trustees William Cheung, who lives and practices in Hong Kong, was part of the team that has traversed China to negotiate and sign Memorandums of Understanding (MOUs) for exchanges with dental schools there. Cheung is also the Director of the FDI World Dental Federation's Continuing Education Program for the Asia Pacific region.

Trekking China
Over the last five years as the Penn team traveled across the country, its members lectured in nine major dental schools, taught short courses in three, collaboratively organized and conducted four major symposiums and three hands-on courses for dentists gathered in Penn's new PWCC facilities.

They are currently organizing two more in-China symposiums later this year at which 1,000 attendees are expected, and are conducting increasing numbers of smaller, live-video presentations by faculty members speaking from Philadelphia to Chinese academics gathered in the auditorium of the PWCC in Beijing.

The dental school team has also received a grant from Penn Global's China Research and Engagement Fund to organize a large forum on "Dental Care in China" at the PWCC in the fall of 2017.

Great structural change
"There is great change going on in the structure of dentistry in China," said Penn Dental Professor Songtao Shi, an international authority on dental stem cell research who earned his Doctor of Dental Surgery degree at Peking University before coming to the U.S. to earn his PhD.

"Private practice is relatively small but growing, and those offices need education to maintain their quality," continued Shi, who is Chair of the Penn Dental Department of Anatomy & Cell Biology. "At the same time, dental teaching hospitals that used to run with government money no longer get government money. So now they have to balance how much actual teaching they can do against the amount of service they must provide to their panel of patients. Those daily services are the new way they make their income."

In virtually all their travels across China's vast landscape, the Penn team has found far-flung communities of dental professionals to be hungry for information about the latest dental techniques and technologies.

Toward stability
"They inherited training practices from the Russians and are now learning from the Americans," said Shi. "Their education system is not stable yet, but we think it will become stable over the next several years."

"China now realizes that their dentists have to have much better clinical training," said Kim. "That's why we are so busy and are becoming more so. Whenever we hold a symposium there, thousands of people show up. It's incredible. A PWCC hands-on course is totally booked within days of its announcement."

Caption

In the oral cancer surgical suite at Shanghai Dental School are (l to r) William Cheung; the facility’s Chief of Surgery; Anh Le, Chair of Penn Dental Medicine Oral Surgery; and Syngcuk Kim. See larger image.

Meanwhile, back on the Philadelphia campus, 24 assistant, associate or full professors from collaborating Chinese dental schools have come to Philadelphia to study clinical procedures for stints of three or six months over the past five years. Separately, 20 additional Chinese exchange academics and researchers have completed up to three years of PhD level courses on the Philadelphia campus. These programs immerse both groups in the latest research techniques and technologies. Meanwhile, the cross-cultural interaction builds long-lasting personal bonds.

Educating Chinese educators
"Dr. Kim and Dr. Shi are actually educating the Chinese educators of the future and all of them will be Penn trained," said Kinane. "The whole thinking in a nutshell is that we have them in our labs doing research. That's a win for us. The experience is also a big win for them. It's also a big win on the clinical side for China to be able to send people to our clinics for education that opens their eyes to the Western way of delivering dental care."

Beyond training Chinese dentists, Penn Dental is also working to establish exchange programs that would enable its own U.S. students to study in China with top specialists there.

"Shanghai Dental Hospital has the best oral cancer surgical team in the world," Kim explained. "They do five cancer surgeries per day. We have signed a memorandum of understanding with them and are actively talking about sending our oral surgery residents there for a month or so."

Beyond the government dental hospital system, Penn Dental is also focusing on the emerging market for private practice dental care. It's estimated that private dentists make up about 10 percent of the overall market but the public desire for such services is growing as the middle class population increases. During the last five years, the number of private dental offices has increased by 50 percent.

Growth of private practice
"Many patients don't want to wait in day-long lines and they have the money to take advantage of private practice," said Kim. "The offices of these new businesses are beautiful -- they look like American dentist offices -- but their general dentists are not well trained like ours. The businessmen who run these companies know the kind of training their clinicians need but don't know where to get it. That's where we come in."

"There is an offshoot of the Lenova computer company in China called Bybo that is talking to us about working with them to train their dentists," said Kim. "That's just one company. We're already working with Arrail Dental, a Beijing company whose CEO is Robert Zou, a Wharton alumnus. We also have plans to go into other areas such as the Guangzhou area near Hong Kong because there are lots of private dentists there."

"All these educational efforts," said Dean Kinane, "are not so much about money as they are about brand building right now. We are broadly involved in collaborations so that we can position ourselves as the 'Coca-Cola' brand of dentistry in China at the very beginning."

A Penn dental school in China?
Does the dean envision actually building a Penn Dental Medicine school in China in the future?

"No," said Kinane. "We think there's too much risk and complexity to do that well. I think the critical thing is preserving your brand, keeping within your regular business model and being very careful about branching out into others."

Kinane noted that he was also closely watching what other U.S. universities are doing in China.

"If building medical schools in China was going to be such a great adventure," he said, "then Michigan, NYU and Harvard -- the smart schools -- would have been there already. But today, like Penn, they're not."

~ ~ ~
Hoag Levins is the Editor of Digital Publications at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI), and a former staff reporter and editor at newspapers and magazines in Philadelphia, New York and Washington, D.C.